COMMUNITY HOSPITALS STRATEGY REFRESH

Transcription

1 COMMUNITY HOSPITALS STRATEGY REFRESH

2 FOREWORD BY THE CABINET SECRETARY FOR HEALTH WELLBEING AND CITIES STRATEGY Community hospitals in Scotland occupy a unique niche in the Scottish health and social care landscape. Furthermore they have a rich cultural heritage, with many of the services and facilities pre-dating the creation of the NHS. Since their formation, community hospitals have continually evolved and today they are more important than ever in providing both health and social care services for local communities. The Scottish Government s vision for the future provision of health services in Scotland centres upon the Quality Strategy (2010) and the six Quality Ambitions: Person Centred; Safe; Effective; Efficient; Equitable; and Timely. At the heart of delivering these quality ambitions are the plans to integrate health and social care. A key part of integration is continuing to drive forward the work in shifting the balance of care from large institutions into community settings. As such, it is envisaged that community hospitals will play a vital role in delivering a significant change in the provision of both health and social care in Scotland. This strategy refresh develops the work started by the Developing Community Hospitals: A Strategy for Scotland (2006) by providing a new direction and fresh focus for these valuable resources. The strategy delivers a bright vision for the future development of community hospitals through: ensuring that people who utilise community hospitals are the centre of care pathways; providing provision for the development of the workforce in community hospitals; and identifying how community hospitals can de developed to better provide for local communities. The Scottish Government will be promoting the development of community hospitals and community hospital staff through the creation of an Improvement Network and a short life working group. The Improvement Network will be developed in collaboration with community hospitals and hosted by NHS National Education Scotland. It will provide a portal for development opportunities for community hospital staff. The working group will provide support for the development of the clinical side of community hospitals. I

3 In addition to the working group and the Improvement Network, a set of actions has been drawn together in this strategy that will be taken forward by NHS Boards. The outcomes of these actions will provide the blueprints for NHS Boards and Community Health Partnerships to not only develop modern, locally sustainable community hospital services that are responsive to local community needs, but to also enable community hospitals to fulfil a valuable role in a modern Scottish health and social care service. Community hospitals will remain a key resource for the people of Scotland which must be refocused to meet the changing needs of the population. This strategy refresh outlines how community hospitals, NHS Boards and the Scottish Government can best achieve the redevelopment of our valuable community hospitals in order to deliver a person centred, safe, effective, efficient, equitable and timely service to the community. Nicola Sturgeon, MSP Cabinet Secretary for Health, Wellbeing and Cities Strategy April 2012 II

4 Contents Executive Summary Section 1: Building a better picture of care provision What Are Community Hospitals? What Do Community Hospitals Do? (a) Rehabilitation in a community hospital (b) Community services, diagnostics and outpatient services How can Community Hospitals Develop to Improve Patient Outcomes? Section 2: Delivering better outcomes for patients Putting Quality at the Heart of What We Do Demographic Change Integration of Health and Social Care Community Based Services Managing Patient Pathways in the Community Working with Secondary Care Rehabilitation, Enablement and Intermediate Care Specialising Assessing the Best Use of Resources Broadening the Services Available Working With Communities Developing the Workforce Section 3: Delivering the changes The Scottish Government NHS Board Actions Additional Support and Programmes of Work The Scottish Association of Community Hospitals Section 4: Reference List Key Strategies Academic References Web References Data Sources Annex 1: List of Community Hospitals in Scotland Annex 2: Specialities in Community Hospitals in Scotland III

5 Executive Summary 1. Since Developing Community Hospitals: A Strategy for Scotland 1 was published in December 2006 there have been significant changes in the policy landscape and the challenges that face NHS Scotland and its partners. The pressures of demographic change and technological advances have expanded the range of options that may be provided in a community setting. There is a greater opportunity than ever before to provide more integrated community services that anticipate and address the needs of those most at risk, and community hospitals will sit at the heart of this for many areas. 2. A common feature across the community hospital estate is variability. They differ in size, age, function, staffing, accessibility, condition and links with their local community. This presents opportunities to utilise the variability to develop community hospitals to match the needs of the local populations and support the broader challenges faced by NHS Scotland and its partners. The Healthcare Quality Strategy for NHS Scotland 2 provides the framework for the ongoing development of community hospitals in Scotland as part of an integrated health and social care system. 3. This document builds on the Developing Community Hospitals: A Strategy for Scotland and reflects on how current strategic priorities should influence the vision for community hospitals. Planning services should reflect key policy drivers and deliver high quality, accessible and sustainable care as locally as possible to where the person, their family and/or their carers live. It is the tenets within the broader policy agendas noted below that will provide direction for community hospital development and ensure that they play their full part in improving outcomes for patients across Scotland. This document connects to: Healthcare Quality Strategy for NHS Scotland; Reshaping Care for Older People; Integration of Health and Social Care; Delivering for Remote and Rural Healthcare; Intermediate Care Framework; Living and Dying Well: A national action plan for palliative care and end of life care in Scotland; Scotland s National Dementia Strategy; NHS Scotland Efficiency and Productivity Framework for SR10; Shifting the Balance of Care; AHP Delivery Plan This document seeks to demonstrate, through examples of good practice, how community hospitals can become more effective in the delivery of improved pathways of care, especially with regard to supporting the older population. It is primarily aimed at NHS practitioners from primary, community and secondary care, 1 Developing Community Hospitals: A strategy for Scotland; Scottish Government; Dec The Healthcare Quality Strategy for NHS Scotland; Scottish Government; May AHP Delivery Plan Consultation 1

6 social work teams and managers who work in and with community hospitals but will be of interest to wider stakeholders, such as the public and third sector partners. 5. Community hospitals are well placed to support patients on their journeys of care through the health and care system. They should provide a hub for community services, telehealth and anticipatory care, make most effective use of inpatient and ambulatory services offered locally, including rehabilitation, reablement and specialist dementia and palliative care services. Through the provision of these services, community teams can help to prevent emergency admissions to acute hospitals and will play a significant role in supporting the reduction of hospital delayed discharges from the current maximum wait of six weeks to 14 days by April Not all community hospitals will be able to provide all of these functions. It is therefore essential that community hospitals are included within local service plans, care pathways and workforce development so that staff and the public are clear about the role of community hospitals and that they are well linked to other appropriate health and social care services. 7. The Scottish Government s commitment to integrating adult health and social care, and the planned Intermediate Care Framework 4, will have significant impact on the care provided by community hospitals, especially their links with care home and home care support. These agendas will require local teams to knit community hospitals into the fabric of local care and support services, ensuring improved outcomes for patients. 8. This re-setting of community hospital priorities may see some facilities expand the clinical services they offer, others specialise in a small number of clinical areas and some reduce their inpatient capacity to support more appropriate community based services. These changes to service provision will require careful planning and the involvement and support of local communities and clinicians is essential to ensure that the right services are developed to match the needs and expectations of the communities they serve. 9. To improve outcomes this document outlines a number of actions that will be taken forward over the next two years. These include: The Scottish Government will support NHS National Education Scotland to develop, in consultation with community hospital staff, a national network to facilitate education, sharing of good practice, exchange of knowledge and clinical skills and to provide an improvement forum; The Scottish Government will convene a short life working group for community hospitals with a remit to look at the challenges of delivering medical cover, in and out-of-hours within community hospitals; NHS Boards will ensure that each community hospital has a clear service plan that identifies its role and maximises its contribution to managing demand and 4 Intermediate Care Framework, due to be published in 2012, The Scottish Government 2

7 delivering outcomes within specified care pathways. These will be agreed with clinical teams from primary and secondary care; NHS Boards will review and address the learning needs and improvement capability and capacity of their community hospital workforce, particularly around the care of older people, those with dementia and delirium and the need for rehabilitation, reablement, palliative and end of life care; NHS Boards will ensure that Geriatrician, Psycho-geriatrician, Community Paediatricians, Palliative Care, rehabilitation and pharmacy support is embedded within the community to support GP led and shared care inpatient services for older people; NHS Boards will ensure that all staff involved in the transfer of patients from acute sites to local community hospitals are fully aware of the differing admissions criteria in place in each facility; NHS Boards will ensure that community hospital staff engage with the local community health and care services that might be utilised to support their patients onward care journey; NHS Boards and ISD will work together to ensure coding of community hospital facilities reflects their current function, while ensuring that any changes made do not have a negative continuity impact on the data that underpins our HEAT targets and other priorities, or if it does impact that we are well prepared to revise data to keep robustly in-line with the targets; NHS Boards will ensure that their ehealth strategies enable IT and telehealth capability at appropriate community hospital sites; NHS Boards will ensure that the actions contained within their Property and Asset Management Strategies and infrastructure plans support the delivery of the service plans establishment for their community hospitals; NHS Boards should continue to make use of results of the inpatient patient experience survey to support local improvement work including work in community hospitals. 3

8 Section 1 Building a better picture of care provision What Are Community Hospitals? 10. Community hospitals in Scotland have a rich history. Many of the services and facilities started before the creation of the NHS, funded by local benefactors and often built as fever hospitals or war memorials. They are spread across 11 NHS Boards, providing over 2,900 inpatient beds and over 750,000 outpatient, allied health professional and nurse led appointments 5. They remain the heart of health services in many rural and remote communities allowing access to more specialised services and inpatient facilities closer to home. 11. There is no official definition for a community hospital in Scotland though the most commonly used is Sir Lewis Ritchie s: A community hospital is a local hospital, unit or centre providing an appropriate range and format of accessible health care facilities and resources. Medical care is normally led by GPs, in liaison with consultant, nursing and allied health professional colleagues as necessary and may also incorporate consultant long stay beds, primary care nurse-led and midwife services. 6 More recently, many community hospitals have co-located social care practitioners and other staff to facilitate more joined up care for patients and service users. This has included an expansion in co-location with minor injury units and the Scottish Ambulance Service. Co-location has significantly helped to improve joint working across the professions. 12. There is also no definitive list of community hospitals in Scotland though two are widely used and accepted. The first, the official data return gathered by NHS Information Services Division (ISD), lists 58 community hospitals across Scotland. The second, collected by the Scottish Association of Community Hospitals includes a further 34 hospitals (Annex 1). This difference highlights the changing nature of care offered by facilities within the community and the difficulty in categorising community hospitals. 13. Analysis on both lists show similar patterns of variation across the size, the specialties offered, the cost per bed day, length of stay and a range of performance measures used to assess performance of acute facilities. The data analysis exercise also highlighted that there is little or no correlation between these factors on either dataset. One must conclude, that there are significant challenges at looking at comparative data across these variable facilities at a national level 7. 5 Information Services Division, SMR00 & SMR01 6 Richie LD; Community hospitals in Scotland; promoting progress; Aberdeen: Department of General Practice and Primary Care, University of Aberdeen, Community Hospital Data Paper; Scottish Government. Available on request 4

9 14. A study carried out in the UK by Small et al 8 compared the philosophies of care between six community hospitals (of varying size, location and age) with four district generals hospitals. The study concluded that: there were stated similarities between general hospital and community hospital services but that community hospitals aimed to provide a more homelike style of care (Figure 1). These aspirations were realised to the extent that they were both recognised and appreciated in patient and caregiver interviews. This homelike style of care is an attribute of recognisable importance to patients and one they linked with the promotion of recovery and independence. Figure 1 from Small et al (2009): Similarities and differences between the philosophies of care of community hospitals and general hospitals. These points were generated from semi-structured interviews with 42 staff from six community hospitals and four district general hospitals. 15. Community hospitals are hard to define, compare and categorise and they have a different philosophy of care when compared to larger hospitals. Each hospital provides a different range of specialist services (see Annex 2), however, it is this flexibility and person centred approach to care that makes community hospitals so 8 Small et al (2009) Post-acute rehabilitation care for older people in community hospitals Philosophies of care and patients and caregivers reported experiences: A qualitative study. Disability and Rehabilitation. 31:

10 valuable. In developing the services they provide to improve the health of the local population, we must not lose sight of these factors. 16. They are usually led by local GP practices who provide the clinical leadership and the focus of the services that the community hospital offers. The medical teams work is underpinned by Nursing, Allied Health Professionals and social work teams who deliver the majority of the care and support to patients. Ensuring that these professionals are supported in these roles and have time to work together will ensure the continuity of care and support that community hospitals need to deliver. What Do Community Hospitals Do? 17. In simple terms community hospitals have three main functions. First, they support the rehabilitation and recovery of patients after a stay in an acute hospital; second, they provide the specialist end of community services, whether this be coordinating care around high risk patients, providing/co-locating services that patients have traditionally had to travel to bigger sites for and beds for clinical specialties (such as palliative care and mental health); third, they provide some diagnostic and out patient services. The majority of community hospitals and the clinical services they provide will see patients in most of these categories. a. Rehabilitation in a community hospital 18. Patients who have undergone treatment at a major acute site, but are stable and no longer need to receive specialist acute care, can be transferred to a community hospital to continue their rehabilitation before being discharged. This ensures that patients are treated in the most appropriate setting, with the right level of care, are often closer to home for friends and families to visit and is often a more relaxed atmosphere than a major acute site. Transfer to a community hospital frees up specialist beds in acute hospitals ensuring their more efficient use. 19. It is critical that community hospitals understand their contribution to the whole system in terms of patient flow and that they need to be looking to pull those patients who are ready for and will gain from the services which they provide without delay. This is in order to prevent any delay in providing the treatment in the community while ensuring that beds are available in a timely manner for those patients requiring treatment in an acute setting. 20. The move to a community hospital will put the patient back under the care of a local GP/GP practice extended team and discharge for patients can then be better integrated with local community and social care services, especially where these have been co-located into community hospital facilities. 21. There is a growing academic evidence base comparing the clinical outcomes for patients who have a period of rehabilitation within a community hospital as opposed to a general hospital 9,10,11. The studies demonstrate that patients have 9 Garåsen et al (2007) Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trail. BMC Public Health. 7: Young et al (2007) Postacute Care for Older People in Community Hospitals: A Multicenter Randomized, Controlled Trial. JAGS. 55:

11 greater independence once they return home where their rehabilitation has been conducted within a community hospital as opposed to a general hospital. The use of an intermediate care team supports this process. b. Community services, diagnostics and outpatient services 22. Community hospitals provide patients with more intensive clinical input than can be provided in their own homes without the need for admission to a district general hospital or a major acute site. This ensures that patients are seen closer to home by local primary care and social work teams, providing good continuity of care and better transitional arrangements for the patient. Telehealth solutions can be utilised to provide some of these services and are often cost effective in remote and rural areas. 23. A number of community hospitals provide specialist services that have been traditionally offered at large acute care facilities. This includes specialist inpatient services such as dementia care, diagnostic tests and procedures, minor injury services or general clinical services. This ensures that services are delivered as close to patients as possible and in remote and rural areas of Scotland this can result in patients savings hours of costly transport to and from major centres and the stress and other opportunity costs associated with travel. How Can Community Hospitals Develop to Improve Outcomes? 24. The evidence is clear that community hospitals provide clinically effective services that improve the outcomes for patients and support the delivery of services closer to home. In the 2011 hospital inpatient experience survey results 12, from the 44 community hospitals that responded with sufficient data, the scores for the majority of questions were either on a par with the national average or significantly higher. NHS Boards should continue to make use of results of the inpatient patient experience survey to support local improvement work including work in community hospitals. 25. The main challenge for NHS Scotland has been to ensure that community hospitals are fully aligned and linked to the wider delivery of services within NHS Board areas. In order to make full use of these valuable resources, it is vital that community hospitals are as effective as possible at delivering pathways of care and have clear links with the broad range of services provided by the NHS and it s Partners and in particular, acute hospitals, care homes and social care services. The results from the inpatient surveys indicate that on going care after hospital treatment is of concern to a number of patients that have attended community hospitals and as such, the links with on going care such as social services and care homes should be strengthened. 26. NHS Boards need to ensure that strong relationships are built up with other areas in the system, whether this be with secondary care services and clinicians or 11 O Reilly et al (2008) Post-acute care for older people in community hospitals a cost-effectiveness analysis within a multi-centre randomised controlled trial. Age and Ageing. 37:

12 community based teams and facilities such as care homes. Community hospitals that work in isolation lessen the impact that they have improving patient outcomes. The inpatient experience data is seen as an important indicator of performance. In the future community hospitals should look to actively work with the Better Together Scotland team to improve the dataset for community hospitals and patients should be encouraged to submit feedback through this forum. Furthermore, each hospital should be seen to be trying to improve on this years score. 8

13 Section 2 Delivering better outcomes for patients Putting Quality at the Heart of What we do 27. The overarching context for the ongoing development of community hospitals in Scotland is the Healthcare Quality Strategy (Scottish Government, 2010). The Quality Strategy identifies three Quality Ambitions which act as the focus for priority action for all services. The three Quality Ambitions are: Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making; There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times; The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit and wasteful or harmful variation will be eradicated. 28. Six healthcare Quality Outcomes will provide a more comprehensive description of the priority areas for improvement in support of the Quality Ambitions and provide a context for partnership discussions about local and national priority areas for action. 29. For community hospitals this means identifying and supporting patients on their journey of care through the health and care system. The hospital should ensure that: appropriate patients are being seen at the right time; patients have clear clinical care plans and are involved in their own healthcare decisions; and patients are discharged safely when they can be better cared for in another setting. A recent joint study carried out by NHS Education for Scotland (NES) and the Scottish Association of Community Hospitals 13 highlighted concerns made by staff working in community hospitals that some patients had been referred to them inappropriately. This should be a particular focus for community hospitals. The work progressed on anticipatory care planning, and intermediate care teams will be essential to driving forward improvements. 30. It means supporting the clinical and professional teams that work in community hospitals to improve skills to deliver the necessary specialist services that are required locally. Improving joint working with secondary care, community teams, local care homes and social care to draw on their skills to ensure that patients receive effective care within the hospital and a smooth transition onwards on their care pathway. Ensuring secondary care expertise is available in the community and the work undertaken in partnership with COSLA, Scottish Care, the care home regulator and other key stakeholders to enhance the quality of care being provided, 13 Identifying the Learning Needs of Community Hospitals in Scotland 9

14 and the services offered, by care homes through the National Care Home Contract is key to this. 31. In some cases it may be about making the decision to redirect resources from community hospital inpatient beds to community services that can better provide the support and care that patients require. NHS Boards working with health and social care professionals need to be able to clearly demonstrate how these facilities function within the wider health and social care system for the benefit of the patients that they serve and make the necessary changes to facilities to ensure they are delivering care that is safe, effective and person-centred. The development of clear locality based pathways of care by NHS Boards will be essential to ensuring that community hospitals can play their full part in delivering better outcomes for patients. Demographic Change 32. The Reshaping Care for Older People ten year programme of work 14 sets out the strategic direction for service development to support the aging population. At its heart is the shift of services and resources to support people within their own homes and through community facilities. This focus puts the person at the centre of the decision making process, provides them with the support they need to keep healthy and safe and reduces the incidences of unplanned admissions to hospitals that can be so disruptive to people s lives. 33. The majority of patients that community hospitals support are older people and with growing demographic pressure it is likely that the role of community hospitals in providing care for this group will increase. NHS Boards will need to consider the implications of this for community hospitals and community based services to effectively manage this expanding group of patients, many of whom will have multiple long term conditions, including in many cases dementia. 34. A notable consequence of demographic change is the increasing age of patients cared for within community hospitals. This influences the care needs of patients but also the ability of staff to adapt the environment of care to meet the needs of different care groups. For example adults with acquired brain injury may share the same facilities with much older people with dementia. An environment designed for older people with dementia may not be appropriate for younger people with physical disability or alcohol related brain injury. NHS Boards must ensure that patients are cared for in appropriate and enabling environments. Integration of Health and Social Care 35. Scottish Ministers have announced proposals to further integrate health and social care services 15. The proposed reforms will focus on: Nationally agreed outcomes that will apply across health and social care, focusing in the first instance on older people s services; 14 Reshaping Care for Older people: A programme for Change ; The Scottish Government, COSLA, NHS Scotland

15 Joint accountability to Ministers, NHS Board chairs, Council Leaders and the public for delivery of those outcomes; A single integrated budget that will include, as a minimum, expenditure on older people s community health and adult social care services, and, importantly, expenditure on the use of some acute hospital services; and Strong clinical and professional leadership, and engagement of the third sector, in commissioning and planning of services. 36. The integration of health and social care will have a significant impact on the way that community hospitals are managed and developed. The proposed reforms will include plans to integrate budgets for some acute care, community care and adult social work; thus enabling local teams to ensure that resources match patient needs. This will include the budgets currently set aside for community hospitals. 37. It will be essential for community hospitals to proactively engage with this agenda to ensure that their considerable resources are utilised in the best way possible and they should be looking to develop their service provision accordingly. For example, where appropriate developing a hospital as a community hub for health and social care 16, or providing a specialist service to the community such as palliative care or dementia services. 38. The Scottish Government will expect significant progress in drawing together health and social care into a coherent, jointly delivered service, whilst the proposals for integration progress through the Scottish Parliament. It is important that, whatever local service model exists, that the hospital service is fully integrated across the spectrum of care. Community Based Services 39. A large proportion of community hospitals provide care, through GP practices, directly to the communities that they serve. This traditional model provides greater clinical options for community teams rather than admission to a major acute site and provides a hospital setting closer to peoples homes. Admissions are usually controlled and coordinated by patients GPs. 40. This is key to providing a community-hub for health and social care and in many of the new facilities they play this dual role. It can provide a base for telecare services and manage patients on a virtual ward basis, bringing those patients in who require a short stay of more intensive medical support whilst actively managing other high risk patients within their own homes. With integrated arrangements between health and social care services, patients conditions are better managed, reducing the need for unplanned admissions to hospital and improving early and preventative intervention. 41. Community hospitals provide the specialist end of community healthcare provision and can be used as a hub to co-ordinate care for their local population. 16 Remote and Rural Steering Group, 2007, The Scottish Government 11

16 They allow community teams an extra clinical option for specialist outpatient and inpatient treatment. The interaction with secondary care colleagues, especially Geriatricians, Psycho-geriatricians, Community Paediatricians and palliative care, helps to develop this role and expand the services that can be offered. Clinical teams are better equipped to judge which patients will benefit most from managed inpatient stays within the community hospital. Targeting the right patients and providing them with the right type of care will reduce the incidence of unplanned admissions to major acute sites and allow teams to manage patients within a community setting. Managing Patient Pathways in the Community 42. The key to successfully managing patients within the community and knowing when and whom it is appropriate to admit is vital to a good understanding of the clinical needs of the local community and identifying those most at risk of a clinical episode. Traditionally this has relied almost solely on GP interaction with their patients but there are an increasing number of tools that can support this process and engage the rest of the community team in the decision making process. 43. Risk Prediction tools such as SPARRA 17, anticipatory care planning, case/care management and Virtual Ward are some of the techniques that community teams use to identify patients who are at risk of an unplanned admission and proactively manage their care. Joint working with social work is essential as often those at high risk require adaptations and specialised equipment within their homes alongside support services. Interaction with care homes is often required as teams provide medical support directly within the care home to allow residents to stay there rather than come into the community hospital. 44. The basis of both anticipatory care and Virtual Ward involves risk modelling to identify people who are likely to have a clinical incident now, or in the near future. The provision of health and care services to support the identified cohort of patients reduces the risk that they will have an unplanned admission. The inclusion of secondary care colleagues within the management group strengthens the ability of the team to make the best decisions for patients. These initiatives strengthen community response and ensure that specialist acute services are used by those who require them most. On Going Case Study - Virtual Ward (NHS Tayside) What is a Virtual Ward? In a Virtual Ward there is no physical building to which patients are admitted. They are cared for in their own communities, usually at home, using an admission method based on a computer based, risk stratification tool (RST). This method identifies patients at an early stage of their illness and aims to reduce preventable hospital admissions by helping better manage their conditions at home. Tayside case study 17 SPARRA (Scottish Patients At Risk of Readmission and Admission). For further information see: 12

17 There are currently tests taking place across the three CHP's in NHS Tayside with 13 GP practices and multidisciplinary teams, supported through a development LES until May A RST is being used to identify patients suitable for assessment and who may benefit from a virtual ward admission. The RST identifies people aged 40 and above using the GP practice based data from Vision, generates a risk score reflecting risk of admission in the coming year. The tool has only been fully operational with these teams since April 2011 and the identified people are many and varied but the disease areas are based on QOF. The learning relating to the documentation and sharing of information has led to the development of Virtual Ward in MiDIS which will allow sharing of information across services with appropriate data governance. There is a consensus though, that the virtual ward concept is supporting a move towards better MDT working, anticipatory care planning and support for self management. Information supplied by Sandra Gourlay (NHS Tayside; sandra.gourlay@nhs.net) Additional contacts: Gail Young (Dundee CHP; gail.young@nhs.net) Rhona Guild (Angus CHP; rhona.guild@nhs.net) Anticipatory Care (NHS Highland) Issue In the UK, the over 65 year old population is increasing rapidly. Multi-morbidity places more demands on all health services including end of life and palliative care. This population are at high risk of hospital admissions, some of which are potentially avoidable. Solution A single GP practice was used to trial Anticipatory Care Planning. Anticipatory Care Planning has been described as a process of discussion between patient and a professional carer, which sometimes includes family and friends. High risk patients were identified and then offered an Anticipatory Care Plan (ACP). ACPs aim to provide a patient centred, cost effective approach to patients with multiple morbidities and illness trajectories that will deteriorate. Outcome 80 survivors from the ACP cohort and 81 survivors from a control cohort were used in the study. The following results were reported: - The survivors from the ACP cohort had 510 fewer days (52% reduction; p=0.020) in hospital than in the previous twelve months, compared to a 12.7% reduction in the control cohort (p=0.188). There were 37 fewer admissions by the survivors from the ACP cohort post intervention (42.5% reduction; p=0.002) compared to 23.8% reduction in the admission rate in the control cohort (p=0.087). - The cost of unplanned hospitalisation for the survivors from the ACP cohort fell by 161,944 (48.6% reduction; p=0.029) compared to the cost for the survivors from the control cohort which fell by 50,163 (12% reduction; p=0.221). - There was a significant difference (p=0.007) in the proportion of deceased patients that died in hospital, with three deceased ACP patients dying in 13

18 hospital compared to 11 deceased patients from the control cohort. Therefore, it is anticipated that ACP will help to deliver an outcome (death at home) that the NHS is historically poor on delivering. Further work Following the successful trial, ACP has now been rolled out across the whole of NHS Highland and approximately 4,000 patients are now in receipt of this plan. Information supplied by Adrian Baker 45. The use of these systems in areas where there is community hospital provision ensures that the right patients are admitted, when they require intensive clinical support. A better understanding of the local population and their needs will ensure that the right balance of resources is invested in the hospital and community services. Working with Secondary Care 46. In the vast majority of community hospitals, work is undertaken by primary care multidisciplinary teams with support from secondary care consultant colleagues to provide significant benefits for patients. Joint working and shared care provides primary care colleagues with a greater understanding of clinical specialism and for secondary care colleagues a better understanding of the care and support delivered within primary care. 47. The support of geriatricians and psycho-geriatricians are particularly key given the demographic of patients that community hospitals largely serve. Better joint working between clinical colleagues allows patients to be supported within the community for longer and often results in a shorter length of stay at acute facilities as community hospital teams become more confident in looking after people with more complex support needs. NHS Boards should seek to promote closer collaboration between the GP leads that provide medical cover in community hospitals and appropriate secondary care colleagues. Community Geriatrics Example of Best Practice (NHS Highland) A Consultant Geriatrician based at Raigmore District General Hospital started working at County Community Hospital Invergordon in June 2007 on a part time basis. Invergordon is a 32 bedded unit in a modern building. Prior to June 2007, the 32 beds were split into two 16 bed wards: one run by GPs, the other run by a Consultant. Three changes were implemented in June 2007: - The two wards were combined and co-run by the GPs and the Consultant; - A weekly, joint GP/Consultant ward round of all patients in the hospital was started (arrow 1 in the graph indicates when this initiative was started); - And a weekly, joint multidisciplinary team meeting was started. This was initially between the Consultant and GPs, but now social workers, home care organisers, local community nurses and allied health professionals attend as standard. 14

19 In February 2010, the multidisciplinary team meeting was extended to discuss patients active to the community teams, but who were not currently receiving treatment at Invergordon. A small budget of 30K was set up to allow the community teams to directly spot purchase home care. The aim of this was to allow patients to be discharged quicker and also to avoid admission in the first place (arrow 2 on the graph indicates when this initiative was started). The results of the changes made in Invergordon were recorded by looking at the turnover and occupancy of the over 75s at County Community Hospital Invergordon over time. These are displayed in the graph below: % Apr-05 Oct-05 Apr-06 Oct-06 Apr Oct-07 Apr-08 Oct-08 Apr-09 Oct-09 Apr-10 Oct-10 Occupancy % Length of Stay Apr-11 Discharges 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Over time, the occupancy levels in the community hospital (green line) has risen. The discharge rate (red line) and length of stay (blue line) indicate that the increase in occupancy is not due to patients increasing their stay at the hospital. Furthermore, the figures for the number of beds in Raigmore District General Hospital occupied by patients over 75 show an overall decrease since (data not shown). The data demonstrates that the initiatives and joint-working that has been put in place at Invergordon is having a real impact on the outcomes of patients. The community hospital is better utilised, patients are treated in their community and discharged quicker to home and fewer patients need to travel and be admitted to Raigmore Hospital, freeing up space for other patients and cutting the expense and inconvenience of travelling to Inverness. The team have noted that over time their confidence has built as the have learnt from each other. They are able to treat more patients with more complex conditions than previously and have confidence that the necessary support will be in place in the community. This initiative has linked health and care services from Raigmore, through Invergordon, to people s homes improving patient outcomes in their local community. Information from Martin Wilson (Consultant Physician martinwilson2@nhs.net) Additional contact Jim Hutton (Invergordon Clinical Lead justjim@talk21.com) 15

20 Rehabilitation, Enablement and Intermediate Care 48. Much of the work progressed under Reshaping Care for Older People will support the reduction of unplanned and unnecessary admissions to major acute facilities but there will always be a number of patients who require specialist treatment in such a facility. Many of these patients will need rehabilitation and reablement after an operation or stay in hospital through local community services. The Intermediate Care Framework will set out how acute and community teams can be developed to provide a range of enabling and intermediate care functions within a variety of settings, including community hospitals. To ensure a person has the opportunity to recover fully it may be appropriate for a period of intermediate care to be provided within a community hospital. This can provide an individual with a period of rehabilitation and enablement which can often avoid the need for an admission to long term care. 49. For this to work effectively and to achieve the best outcomes for the patient, co-ordinated admissions and discharge planning between the acute sites and the community hospital wards must be in place. By providing a range of different skills mix, facilities and clinical capacity, community hospitals are well placed to provide intermediate care, which could avoid the need for an acute admission, or facilitate a timely discharge from that setting. When developing intermediate care services and teams, NHS Boards should consider how community hospitals can best support these initiatives. 50. Acute centres also need to be aware of the different types of intermediate care that may be available within community hospitals to ensure patients are able to access it when needed. Community hospitals may also benefit from reviewing their models of health and care provision. Moving from traditional models which focus on patient s problems and needs, to those which focus on patient outcomes and build upon assets and abilities, can help to promote self management and independence. 51. Any intermediate care provided should be time limited and based on a clear set of outcomes agreed with the patient and their family, or carers. There is evidence to suggest that access to a Comprehensive Geriatric Assessment (CGA), for those who would benefit the most is highly desirable. Randomised control trials of CGA also show that care organised in a Medicine for the Elderly ward increases the proportion of older people who return home from hospital, reduces length of stay and admission to care homes. 52. Early involvement of social care teams in this planning is essential to ensure that when patients are clinically fit to leave hospital the appropriate support packages are in place so they can be discharged and returned home. Co-location of health and social care teams on a single site can significantly support this joint working and planning for the needs of individual patients. 16

21 Specialising 53. A number of community hospitals or wards within them specialise in providing palliative care or services for people with dementia. The requirement for such facilities may well grow as demographic pressures increase over the next two decades. These centres are specialist by nature and therefore require significant specialised training for all staff and greater interaction with colleagues in secondary care. The national Palliative 18 and Dementia 19 care strategies provide the framework in which these services should develop and highlight the importance of strong links to community based services and interaction with family and carers. When designing new or refurbishing existing community hospitals, good practice design principles should be applied. 54. The flow of patients into these facilities requires cognisance and co-ordination with the pathways that have led patients to be admitted. If they have come through the acute sector then good working relationships need to exist and clear admissions and discharge processes need to be in place. NHS Boards should encourage staff to experience working within these settings to ensure that the most appropriate patients are transferred to them. NHS Boards need to ensure that there is significant joint working relationships with secondary care specialists in place to support these units. 55. Patients may also be admitted from community teams who can no longer provide the support to keep the person within their own home. Community teams should be proactively managing the most high risk patients within the community and communicating with these specialist facilities. Through joint working between the teams, the admissions process can be as smooth as possible for the patient without undue distress or the need for an unplanned admission to a larger acute facility. 56. Palliative care units will play a role in supporting patients who wish to die at home or in a homely setting. Links with families, carers, community teams, local care homes and hospices are essential to make this a reality for people and careful planning has to be undertaken between all partners to make sure this happens in a joined up and dignified way. Palliative care (NHS Tayside) Issue Some patients with palliative care needs would prefer to die at home rather than in a hospital. For those with conditions where this is not possible, the view of many is that the next best thing for them and their families is to be able to die close to home in a community based site such as a care home or community hospital. Solution The introduction of a Palliative Performance Scale (PPS) as part of an Advanced or Anticipatory Care Plan (ACP) has been carried out. The PPS is used to assess patients conditions and the level of care that they need to receive. This is carried out for all patients admitted to wards and they are reassessed weekly. These 18 Living and Dying Well: A national action plan for palliative and end of life care in Scotland; September 2008; The Scottish Government 19 Scotland s National Dementia Strategy; June 2010; The Scottish Government 17

22 assessments help in the decision of being able to move patients onto another care facility/home. Example of use An ACP was in place for a gentleman who wanted to die at home with support from his wife, social services and district nurses. The PPS assessed that he would be able to receive suitable levels of care at home; however, documented in his ACP was his wish to return to a local community hospital if things became too difficult for his family or him to cope with rather than a larger acute site. Within a week a phone call was received at the community hospital from Out Of Hours Services (OOH) to readmit the patient. The OOH medical team voiced that they were very impressed with a clear plan of care being in place for a patient they were unfamiliar with and without the documentation the patient would have been admitted to the acute site. Further work All patients/family moving to nursing home care now have the option of having an ACP in place. This has been well received by the patient/family as well as nursing home managers and GPs. Furthermore, it has reduced the amount of calls to OOH, therefore assisting with continuity of care. Information supplied by Duncan Dorothy (dorothyduncan@nhs.net) Assessing the Best Use of Resources 57. The development of community teams and information systems to track at risk patients and the involvement of secondary care colleagues in a primary care setting is important. NHS Boards, multidisciplinary teams and local authorities must look at the current use of resources to ensure that they represent best value and are providing the support required by the local community. 58. For some community hospitals this may require a change in the number of beds or functions to allow resources to be used by alternative community based teams. If Boards are planning to make changes in the use of community hospitals, then these plans and the associated investment/disposal plans should be incorporated within their Property and Asset Management Strategies. NHS Boards must engage proportionately with local stakeholders, including the public, in undertaking these changes; with a clear plan of how resources will shift, what the implications are for local provision of services and how this will support the community over the coming years. 59. Central to proposals of this type will be evidencing change and the Integrated Resource Framework (IRF) will support Partnerships to do this. The IRF enables partners in NHS Scotland and Local Authorities to be clearer about the cost and quality implications of local decision-making about health and social care. It enables better local understanding of costs, activity and variation across service planning and provision for different population groups. 18